Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid Services (CMS), is conducting a post-payment claim review for Medicare home health Part A, for claims billed on dates of service from January 1, 2022, through December 31, 2022. This notification includes the reasons for the review, documentation which will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

The Bipartisan Budget Act of 2018 (BBA of 2018) Title X, §51001 Home Health Payment Reform, outlined requirements for home health payment reform to eliminate use of therapy thresholds effective January 1, 2020. The requirements included patient-focused factors to account for individual beneficiary needs for self-care, quality of care, and resource utilization. The Patient-Driven Groupings Model (PDGM) was a result of the mandated home health payment reform. Units of payment were changed from a 60-day unit of payment to a 30-day unit of payment. The 30-day payment is adjusted to meet the above requirements and further includes patient characteristics, principal diagnosis, secondary diagnoses, and functional impairment level. Occupational Therapy (OT), Physical Therapy (PT), and Speech Language Pathology (SLP), should be determined by the individual needs of the beneficiary without limitations or restrictions.

Reason for Review

The SMRC was tasked to perform data analysis and medical review activities on home health services within the second certification period; the dates of service on review are January 1, 2022, through December 31, 2022.

The SMRC will conduct medical record reviews in accordance with applicable waivers, flexibilities, statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

Access related project details below.

• Documentation Requirements
• References

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review.

Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review:

1. Documentation to support the initial certification period:
   1. All face-to-face (FTF) encounters from start of care
   2. Initial Start of Care Certification
   3. Initial Plan of Care
2. Documentation to support the second certification period:
   1. Recertification for the second certification period
   2. Recertification Plan of Care
   3. Homebound status
   4. OASIS documentation to support the recertification
   5. Beneficiary’s need for the level and frequency of home health services provided, including any changes during the period under review
   6. PT/OT/SLP –Evaluation, plan of care, progress reports, treatment encounter notes, therapy minute logs, and discharge summary to support the second certification period
   7. Home health skilled nursing, home health aide, or rehabilitation therapy notes including evaluations, re-evaluations, progress notes, and actual therapy minute grids to support the second certification period
3. Any other supporting/pertinent documentation needed to support home health services
4. Documentation to support National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and Policy Articles
5. Signature and credentials of all personnel providing services. Include a signature log or signature attestation for any missing or illegible signatures within the medical record
6. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
7. Beneficiary name and date of service on all documentation
8. If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
9. PLEASE NOTE: The supplier or provider is responsible for obtaining all documentation from the ordering/referring provider to ensure medical necessity criteria have been met

References

Social Security Act (SSA) Title XI

• § 1135 Authority to Waive Requirements During National Emergencies

Social Security Act (SSA) Title XVIII

• § 1814 (a)(2)(C), (a)(7) Conditions of and Limitations on Payment for Services
• § 1815(a) Providers Must Furnish Information
• § 1833(e) Payment of Benefits
• § 1835(a)(2)(A) Procedure for Payment of Claims of Providers of Services
• § 1861(m) Definitions of Services, Institutions, etc.
• § 1862 Exclusion from Coverage and Medicare as a Secondary Payer
• § 1879(a)(1) Limitations on Liability of Beneficiary Where Medicare Claims are Disallowed
• § 1895 Prospective Payment for Home Health Services

42 Code of Federal Regulations (CFR)

• § 409.5 General description of benefits
• § 424 Conditions for Medicare Payment
• § 424.5(a)(6) Basic Conditions
• § 424.535 Revocation of Enrollment in the Medicare Program
• §§ 484 Home Health Services, Subpart A General Provisions, Subpart B. Patient Care, Subpart C. Organizational Environment, and Subpart E. Prospective Payment System for Home Health Agencies

Public Law

• Bipartisan Budget Act (BBA) 2018 (Pub. L. 115-123) Division E, Title X, § 51001, Home Health Payment Reform
• CMS Additional Emergency and Disaster-Related Policies and Procedures That May be Implemented Only with a SS 1135 Waiver. Additional Emergency and Disaster-Related Policies and Procedures That May Be Implemented Only With a § 1135 Waiver (cms.gov)
• CMS Covid-19 Emergency Declaration Blanket Waivers for Health Care Providers. Home Health Agencies: CMS Flexibilities to Fight COVID-19
• Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (Pub. L. 116-136). Supporting America’s Health Care System in the Fight Against the Coronavirus
• Robert T. Stafford Disaster Relief and Emergency Assistance Act, Pub. L. No. 100-707, 102 Stat. 4689 (1988), Codified as Amended 42. U.S.C. § 5121. Disaster Relief and Emergency Assistance Amendments

National Coverage Determination (NCD) Institutional and Home care Patient Education Programs, Publication 100-3

• § 170.1 Institutional and Home Care Patient Education Programs

Internet-Only Manual (IOM) General Information, Eligibility and Entitlement Manual Publication 100-01

• Ch. 1, § 10.2 Home Health Services
• Ch. 4, § 30 Certification and Recertification by Physicians and Allowed Practitioners for Home health Services.
• Ch. 4, § 80 Summary Table for Certifications/Recertifications

IOM Medicare Benefit Policy Manual Publication 100-02

• Ch. 7 Home Health Services
• Ch. 16, § 20 Services Not Reasonable and Necessary

IOM, Medicare Claims Processing Manual, Publication 100-04

• Ch. 10 Home Health Agency Billing
• Ch. 23, § 10 Reporting ICD Diagnosis and Procedure Codes
• Ch. 30, § 50 Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN)

IOM, Medicare Program Integrity Manual, Publication 100-08

• Ch. 3 Verifying Potential Errors and Taking Corrective Actions
• Ch. 3, § 3.3.2.4 Signature Requirements
• Ch. 6 Medicare Contractor Medical Review Guidelines for Specific Services

CMS Coding Policies

• Outcome and Assessment Information Set (OASIS)-D1 Guidance Manual. Effective January 1, 2020-current

Local Coverage Determinations (LCD)

• L33942 Physical Therapy – Home Health. Effective October 1, 2015
• L34560 Home Health Occupational Therapy. Effective October 1, 2015
• L34561 Home Health – Psychiatric Care. Effective October 1, 2015
• L34562 Home Health Skilled Nursing Care-Teaching and Training: Alzheimer’s Disease and Behavioral Disturbances. Effective October 1, 2015
• L34563 Home Health Speech-Language Pathology. Effective October 1, 2015
• L34564 Home Health Physical Therapy. Effective October 1, 2015
• L34565 Home Health-Surface Electrical Stimulation in the Treatment of Dysphagia. Effective October 1, 2015
• L35132 Home Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus. Effective October 1, 2015

Local Coverage Articles (LCA)

• A52845 Home Health Skilled Nursing Care: Teaching and Training for Dementia Patients with Behavioral Disturbances – Medical Policy Article. Effective October 1, 2015
• A53050 Case Scenario 1 Home Health Skilled Nursing Care Teaching and Training: Alzheimer’s Disease. Effective October 1, 2015
• A53051 Case Scenario 2-Home Health Skilled Nursing Care Teaching and Training: Alzheimer’s Disease. Effective October 1, 2015
• A53052 Billing and Coding: Home Health Speech-Language Pathology. Effective October 1, 2015
• A53055 Home-Based Fall Evaluations and Interventions. Effective October 1, 2015
• A53057 Billing and Coding: Home Health Occupational Therapy. Effective October 1, 2015
• A53058 Billing and Coding: Home Health Physical Therapy. Effective October 1, 2015
• A56641 Billing and Coding: Home Health Skilled Nursing Care-Teaching and Training: Alzheimer’s Disease and Behavioral Disturbances. Effective July 4, 2019
• A56648 Billing and Coding: Home Health-Surface Electrical Stimulation in the Treatment of Dysphagia. Effective July 4, 2019
• A56756 Billing and Coding: Home Health – Psychiatric Care. Effective August 1, 2019
• A57311 Billing and Coding: Physical Therapy – Home Health. Effective September 26, 2019

Other

• The Centers for Medicare & Medicaid Services (CMS). Home Health Patient-Driven Groupings Model
• CMS. Medicare Learning Network ICN MLN20190214 February 2019. Overview of the Patient-Driven Groupings Model (PDGM)
• CMS. Centers for Medicare & Medicaid Services Patient-Driven Groupings Model. Centers for Medicare & Medicaid Services Patient-Driven Groupings Model (cms.gov)

Last Updated Mar 29, 2024